RWJF Scholar: U.S. Rations Health Care, Too

    • October 2, 2012

Long lines at the doctor’s office. Wait lists for hip replacements or kidney transplants. Denial or delay of treatment for people with cancer or heart disease.

These are the kinds of problems associated with health care rationing—the control or limitation of a health care product or service. Opponents of health care reform warn that problems like these, widely reported to be commonplace in countries like Great Britain and Canada that provide universal health care, will arrive on the shores of the United States under a reformed health care system.

But Beatrix Hoffman, a Robert Wood Johnson Foundation (RWJF) scholar and author of a new book on health care rights and rationing, has some news for those making that argument: health care rationing is already here, and has been for a long time.

“I never want to hear again that the United States doesn’t already ration health care,” she says.

The United States has a long history of rationing health care in a number of ways: by age, income, race, address, employment status, parental status, and by type of insurance coverage, she argues in her new book, Health Care for Some: Rights and Rationing in the U.S. Since 1930.

American-style rationing has led to deep and profound problems, Hoffman argues. The United States spends far more money per capita on health care than any other nation but has the largest number of uninsured and underinsured people in the world—and health care rationing bears some of the blame, she says.

“Every country rations health care, but the way the United States rations it is the most expensive and inefficient in the world,” she says. “We have to admit that we ration, and talk about how to ration in a better, more effective way. Insisting that we don’t just ends the discussion.”

Correcting the Record

Hoffman, PhD, professor and chair of the history department at Northern Illinois University and a recipient of an RWJF Investigator Award, sets out to correct the record in her book, a detailed and sweeping social history of health care rationing in the United States spanning the last eight decades. It will be released next month.

In it, she tells stories of young children like Vera Lahr, who died in 1936 after her regular doctor delayed treatment because he was allegedly annoyed that her impoverished parents had sought free care from charity clinics. She recounts the tale of Emanuel Wilson, a bus driver from New Orleans who survived Hurricane Katrina but faced a grim future nonetheless: The hurricane wiped out his job and his health insurance, but he didn’t qualify for government assistance under Louisiana’s strict Medicaid requirements and had to stop chemotherapy injections for intestinal cancer.

And she describes many more incidents of health care rationing in the years in between.

The history paints a picture of America at odds with one of its foundational principals: rights. After World War II, the world’s industrialized, affluent nations created social and economic rights that included a right to basic health care. America, however did not. It remains the only country in the industrialized world that does not provide some form of health care coverage as a matter of right.

 “We have a greater orientation to the free market,” Hoffman says. “The right to health care conflicts with the powerful idea that health care is a product to be bought and sold.”

The United States did create one important right to health care in 1986, when it enacted a law granting people the right to emergency care. Hoffman argues, however, that the right to emergency care is another form of rationing that has helped drive up health costs.

The 2010 Affordable Care Act does not confer a right to health care, but it does “disrupt” or “improve” the way the United States rations, Hoffman says. The law’s provisions that expand access to health insurance coverage and forbid denial of coverage to those with preexisting conditions are “a great blow against traditional rationing.”

Hoffman’s book grew out of a project she began as a recipient of the RWJF Investigator Award, which she received in 2001. For the project, she explored health care as a right in arenas such as legal challenges to the denial of health care; debates over indigent care; rights in the private insurance system; and the role of race and citizenship.

Her new book, Health Care for Some, published by the University of Chicago Press, builds on an earlier work entitled The Wages of Sickness: The Politics of Health Insurance in Progressive America. That book inspired her to explore the history of health care in the latter part of the century and in the new millennium through the lens of human rights.

After exhaustive research, two books, an edited collection and numerous articles and chapters over the last decade, she comes to a simple conclusion: “We need to ration health care in a more rational way.”

Learn more about the RWJF Investigator Awards program.
For an overview of RWJF scholar and fellow opportunities, visit